Abstract
Introduction
Spinal cord injury (SCI) is a major direct cause of accidental death. Cervical SCI can lead to death in a short time period by neurogenic shock. Prompt vasopressor administration is recommended for patients with SCI accompanied by hypotension (systolic blood pressure < 90 mmHg). We herein present the first fatal case of nonocclusive mesenteric ischemia (NOMI) secondary to cervical SCI in a patient who suddenly died 1 week after an accidental fall.
Case presentation
A 72-year-old man without medical history of cardiovascular disease suffered tetraplegia with a neurological level at C4 after a fall accident. He was fully conscious with stable respiratory ability, and the systolic blood pressure was maintained at >90 mmHg without vasopressor agents. High fever occurred 7 days after the accident and he died in the next morning. Autopsy revealed segmental intestinal necrosis from the ileum to the ascending colon, without mesenteric embolism, or severe arteriosclerosis.
Discussion
This case implies that maintenance of >90-mmHg systolic blood pressure can insufficiently keep the blood flow to prevent NOMI, and the mean arterial blood pressure of >85 mmHg can be more plausible as suggested in the guideline. Monitoring the mean arterial blood pressure in acute SCI is useful not only for neurological recovery but also for the maintenance of vital intestinal perfusion.
Similar content being viewed by others
Log in or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord. 2014;52:110–6.
Osawa M, Satoh F, Hasegawa I. Acute death due to hyperextension injury of the cervical spine caused by falling and slipping onto the face. J Forensic Leg Med. 2008;15:457–61.
Oliver M, Inaba K, Tang A, Branco BC, Barmparas G, Schnüriger B, et al. The changing epidemiology of spinal trauma: a 13-year review from a Level I trauma centre. Injury. 2012;43:1296–300.
Berney S, Bragge P, Granger C, Opdam H, Denehy L. The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: a systematic review. Spinal Cord. 2011;49:17–29.
Velmahos GC, Toutouzas K, Chan L, Tillou A, Rhee P, Murray J, et al. Intubation after cervical spinal cord injury: to be done selectively or routinely? Am Surg. 2003;69:891–4.
Hagen EM. Acute complications of spinal cord injuries. World J Orthop. 2015;6:17–23.
Krassioukov A, Claydon VE. The clinical problems in cardiovascular control following spinal cord injury: an overview. Prog Brain Res. 2006;152:223–9.
Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurg Focus. 2008;25:E13.
Hagen EM, Faerestrand S, Hoff JM, Rekand T, Gronning M. Cardiovascular and urological dysfunction in spinal cord injury. Acta Neurol Scand Suppl. 2011;191:71–8.
Ryken TC, Hurlbert RJ, Hadley MN, Aarabi B, Dhall SS, Gelb DE, et al. The acute cardiopulmonary management of patients with cervical spinal cord injuries. Neurosurgery. 2013;72:84–92.
Stein DM, Knight WA. Emergency neurological life support: traumatic spine injury. Neurocrit Care. 2017;27:170–80.
Garstang SV, Miller-Smith SA. Autonomic nervous system dysfunction after spinal cord injury. Phys Med Rehabil Clin N Am. 2007;18:275–96.
Furlan JC, Fehlings MG, Shannon P, Norenberg MD, Krassioukov AV. Descending vasomotor pathways in humans: correlation between axonal preservation and cardiovascular dysfunction after spinal cord injury. J Neurotrauma. 2003;20:1351–63.
Meaney E, Alva F, Moguel R, Meaney A, Alva J, Webel R. Formula and nomogram for the sphygmomanometric calculation of the mean arterial pressure. Heart. 2000;84:64.
Al-Diery H, Phillips A, Evennett N, Pandanaboyana S, Gilham M, Windsor JA. The pathogenesis of nonocclusive mesenteric ischemia: Implications for research and clinical practice. J Intensive Care Med. 2019;34:771–81.
Stahl K, Rittgerodt N, Busch M, Maschke SK, Schneider A, Manns MP, et al. Nonocclusive mesenteric ischemia and interventional local vasodilatory therapy: A meta-analysis and systematic review of the literature. J Intensive Care Med. 2020;35:128–39.
Acosta S, Ogren M, Sternby NH, Bergqvist D, Björck M. Fatal nonocclusive mesenteric ischaemia: population-based incidence and risk factors. J Intern Med. 2006;259:305–13.
Hong J, Gilder E, Blenkiron C, Jiang Y, Evennett NJ, Petrov MS, et al. Nonocclusive mesenteric infarction after cardiac surgery: potential biomarkers. J Surg Res. 2017;211:21–29.
Minko P, Stroeder J, Groesdonk HV, Graeber S, Klingele M, Buecker A, et al. A scoring-system for angiographic findings in nonocclusive mesenteric ischemia (NOMI): correlation with clinical risk factors and its predictive value. Cardiovasc Intervent Radiol. 2014;37:657–63.
Groesdonk HV, Klingele M, Schlempp S, Bomberg H, Schmied W, Minko P, et al. Risk factors for nonocclusive mesenteric ischemia after elective cardiac surgery. J Thorac Cardiovasc Surg. 2013;145:1603–10.
Muschitz GK, Fochtmann A, Keck M, Ihra GC, Mittlböck M, Lang S, et al. Non-occlusive mesenteric ischaemia: the prevalent cause of gastrointestinal infarction in patients with severe burn injuries. Injury. 2015;46:124–30.
Anderson JE, Brown IE, Olson KA, Iverson K, Cocanour CS, Galante JM. Nonocclusive mesenteric ischemia in patients with methamphetamine use. J Trauma Acute Care Surg. 2018;84:885–92.
Wilcox MG, Howard TJ, Plaskon LA, Unthank JL, Madura JA. Current theories of pathogenesis and treatment of nonocclusive mesenteric ischemia. Dig Dis Sci. 1995;40:709–16.
Katagiri H, Kawarai Lefor A, Kubota T, Mizokami K, Kishida A. Classification of nonocclusive mesenteric ischemia based on the trigger for the disease. Am Surg. 2017;83:e78–80.
Mizumoto M, Ochi F, Jogamoto T, Okamoto K, Fukuda M, Yamauchi T, et al. Nonocclusive mesenteric ischemia rescued by immediate surgical exploration in a boy with severe neurodevelopmental disability. Case Rep Pediatr. 2019;2019:5354074.
Tanaka H, Tsukahara K, Okamoto I, Kojima R, Hirasawa K, Sato H. A case of septicemia due to nonocclusive mesenteric ischemia occurring in induction chemotherapy. Case Rep Otolaryngol. 2018;2018:7426819.
Mitsuyoshi A, Hamada S, Tachibana T, Momono T, Aoyama H, Kondo Y, et al. Pathogenic mechanisms of intestinal pneumatosis and portal venous gas: should patients with these conditions be operated immediately? Surg Case Rep. 2015;1:104.
Landreneau RJ, Fry WJ. The right colon as a target organ of nonocclusive mesenteric ischemia. Case report and review of the literature. Arch Surg. 1990;125:591–4.
Besecker EM, Deiter GM, Pironi N, Cooper TK, Holmes GM. Mesenteric vascular dysregulation and intestinal inflammation accompanies experimental spinal cord injury. Am J Physiol Regul Integr Comp Physiol. 2017;312:R146–r156.
Laird AS, Carrive P, Waite PM. Cardiovascular and temperature changes in spinal cord injured rats at rest and during autonomic dysreflexia. J Physiol. 2006;577:539–48.
Järve A, Todiras M, Lian X, Filippelli-Silva R, Qadri F, Martin RP, et al. Distinct roles of angiotensin receptors in autonomic dysreflexia following high-level spinal cord injury in mice. Exp Neurol. 2019;311:173–81.
Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60:82–91.
Struck MF, Fakler JKM, Bernhard M, Busch T, Stumpp P, Hempel G, et al. Mechanical complications and outcomes following invasive emergency procedures in severely injured trauma patients. Sci Rep. 2018;8:3976.
Hawryluk G, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J, et al. Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma. 2015;32:1958–67.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no competing interests.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Kakimoto, Y., Matsushima, Y., Tsuboi, A. et al. Nonocclusive mesenteric ischemia secondary to spinal cord injury: an autopsy case. Spinal Cord Ser Cases 7, 37 (2021). https://doi.org/10.1038/s41394-021-00402-9
Received:
Revised:
Accepted:
Published:
Version of record:
DOI: https://doi.org/10.1038/s41394-021-00402-9
